How do we deliver & measure the impact of
Recovery based services?
Working with the individual – today
Suzanne Sambrook – Improving confidence in mental health & recovery
Isabel Clarke – The impact of CBT group work on stigma reduction
Andrew Gumley – The impact of attachment based CBT on recovery
Working with staff & teams – tomorrow
Katherine Newman Taylor – Formulating teams to improve recovery
Tess Maguire – How recovery based are our in-patient services?
Sarah Wood – The impact of recovery training on attitudes & behaviours
Recovery Based Group Work:
Building confidence in
recovery
Dr Suzanne Sambrook
Consultant Clinical Psychologist
Southfield Low Secure Unit
Wessex Adult Forensic Service
The challenge
• Traditional bio-medical approach
• Demands of Forensic Services
– Containment vs mental health needs
• Move towards ‘rehabilitation’
• Passivity within the service user group
Wellness Group Programme
Aims:
o To actively involve service users
o To move away from the ‘all-or-nothing’ view of illness
o Emphasise the uniqueness of each individual’s journey
of recovery
o To enhance motivation
o To provide a springboard for further interventions
and work
Themes of the group
Themes based on the principles of Recovery:
o Moving from symptoms & pathology towards health,
strengths & wellness
o Developing a sense of agency
o Changing relationship between professional & service
user (coaches/partners)
o Developing meaningful lives & roles
o Self management
o Developing a sense of hope
o Giving choices
Process
o
o
o
o
o
o
o
Incorporating service users words and ideas
Use of story and analogy
Sharing and commonality
Normalising
Goal setting
Focus on strengths
Enjoyment
Group design
o
o
o
o
o
Attendance of 3 week goal setting group
before attending
Visual aids / Colourful handouts
Interactive exercises
Facilitator involvement
Wellness folders
Wellness Scale
Outcomes
(Mental health confidence scale)
Wellnes Group: Pre & Post scores
80
Mean score on MHCS
75
70
65
Pre group
Post group
60
55
50
Sambrook & Dixon. Motivation and Recovery in a
Low Secure Unit: the Wellness Group.
(in preparation)
Group Feedback “Gave me
ambition”
“Understanding
what illness
means”
“Helped put my
symptoms and
experiences into
words”
What did you enjoy
about the group /
what was good?
“Looking at well &
unwell Jack & Jill was
good fun & very helpful”
“Hard work
but worth it”
“Identifying what is
going to help and
what will make
things worse”
“I was able to recap
on skills / knowledge
from psychology
sessions”
“I found the folder
good so that we can
look back on what
we have done”
Group feedback - Recommendations
“Keep the group
small it was a nice
number”
“Learn how to deal
with problems”
“Do a group where we
discuss & learn what to
do with our early
warning signs”
•What suggestions do
you have for a future
group?
“I would like the group to
go on longer to make
sure we carried on with
our goals. To get together
& discus how we got on”
“More weeks
going into the
subjects in more
depth”
Conclusions & way forward
o The Wellness Group has now become the
cornerstone of introducing Recovery to the
service users
o Of those that attend the group, 75% go on to
attend other groups within the unit
o The majority of service users are offered
WRAP prior to discharge, with a 100% take up
rate to date
Thank you
o To the service users at Southfield for all
the comments about how to improve the
group
o Laura Dixon, Wendy Moody & Claire Field
at Southfield for running and helping to
develop the group
The impact of CBT group
work on stigma reduction
Isabel Clarke
Consultant Clinical Psychologist
Hampshire Partnership NHS
Foundation Trust
The Context
• A 3rd wave CBT for psychosis inpatient programme with a fresh
perspective on psychosis
• Formal evaluation of the programme in its group form
• “Third Wave” – term coined by Hayes (Acceptance & Commitment
Therapy)
• Kabat-Zinn – applied mindfulness to stress and pain
• Segal, Teasdale & Williams – Mindfulness Based Cognitive Therapy
(relapse in depression)
• Linehan – Dialectical Behaviour Therapy (BPD)
• Chadwick – Mindfulness groups for voices
• Change lies not so much in altering thought to alter feeling, but in
altering the person’s relationship to both thought and feeling
• Mindfulness is a key component
• Recognition of a split or incompleteness in human cognition – which
mindfulness can bridge
The Holistic Revolution in Psychosis
•
•
•
•
•
•
•
•
Recognising the role of arousal (Hemsley, Morrison)
Importance of emotion (Gumley & Schwannauer; Chadwick)
Attachment and interpersonal issues (“)
Self acceptance and compassion (“ ; Gilbert)
Self esteem (Harder)
Recognition of the role of loss and trauma
The Recovery approach
All these lead to a blurring of diagnosis
Levels of Processing Theories
• First wave CBT comes unstuck over the gap between logical
reasoning and strong emotion. This leads to the recognition of
different types or levels of processing. e.g. Hot and Cold cognition
(Ellis) – and many more!
• All these theories suggest 2 or more separate types of processing
– the split in human cognition!
• There is one direct, sensory driven, type of processing and a
more elaborate and conceptual one
• The same distinction can be found in the memory
• Direct processing is emotional and characterised by high arousal
• This is the one that causes problems – e.g. flashbacks in PTSD
• The two central meaning making systems of ICS provides a neat
way of making sense of this
Linehan’s States of Mind
(DBT – maps onto Interacting Cognitive Subsystems)
REASONABLE
MIND
(propositional
subsystem)
EMOTION
WISE
MIND
MIND
(implicational
subsystem)
IN THE PRESENT; IN CONTROL
Two Ways of Knowing
• Good everyday functioning = good communication
between the two levels of processing
(ie. implicational and propositional in ICS)
• At high and at low arousal, the implicational (more
holistic) subsystem becomes dominant
• This gives us a different quality of experience – one
that can be either valued and sought after, or
shunned and feared
The Everyday
The Transliminal
Ordinary
Clear limits
Access to full memory and
learning
Precise meanings available
Separation between people
Clear sense of self
Emotions moderated and
grounded
A logic of ‘either/or’
Numinous
Unbounded
Access to propositional
knowledge / memory patchy
Suffused with meaning /
meaningless
Self: lost in the whole /
supremely important
Emotions: swing between
extremes or absent
A logic of ‘both/and’
Taking Experience Seriously in Psychosis
• Acknowledging that psychosis feels different
• Normalising the difference in quality of experience as well as
the continuity
• Positive side as well as vulnerability
• Helping people to manage the threshold –mindfulness is key
• Sensitivity and openness to anomalous experience –
continuum with normality: Gordon Claridge’s Schizotypy
research
• Understanding the role of emotion – where expression of
emotion is not straightforward
Evidence for a New Normalisation
• Schizotypy – a dimension of experience: Gordon Claridge
• Mike Jackson’s research on the overlap between psychotic and
spiritual experience
• Emmanuelle Peter’s research on New Religious Movements
• Caroline Brett’s research: having a context for anomalous
experiences makes the difference between whether they become
diagnosable mental health difficulties and whether the
anomalies/symptoms are short lived or persist
• New chapters by Brett and Jackson in Psychosis and Spirituality:
consolidating the new paradigm – along with new qualitative
research
• Wider sources of evidence – e.g.Cross cultural perspectives;
anthropology. Richard Warner: Recovery from Schizophrenia
Therapeutic Alliance
• As this approach represents a new normalisation, it
can greatly aid the therapeutic alliance
• The individual’s experience is taken seriously and
valued – at the same time as working on a better
relationship to shared experience
• It is possible to get away from illness language –
and arguments about diagnosis
• The schizotypy continuum is a good normaliser –
association of high schizotypy with creativity etc
What is Real & What is Not?
• A 4 session group programme for acute inpatient settings
• Run by staff supervised by or co-facilitated with clinical
psychologist (Mental Health Practitioners, nurses, AOT staff)
• Builds on the Romme and Escher ‘Voices Group’ tradition
• Is different from other CBT approaches in normalizing the
difference in quality of experience in psychosis, as well as
thinking style
• This normalization attacks stigma by associating psychosis
with valued areas such as creativity and spirituality
• Attempts to mitigate the damage to self concept of the
traditional, diagnosis, based approach
What is Real & What is Not?
Signing up for the group
• Validate their reality
• Introduce the idea that their reality is only one way of
looking at it:
• shared and unshared reality (negotiate the language)
• The individual’s experience is taken seriously and
valued – at the same time as working on a better
relationship to shared experience
• It is possible to get away from illness language – and
arguments about diagnosis
The Group Programme: Session 1
Introduce Romme and Escher
Extending from voices to other experiences that
people in general do not share.
Idea of openness to voices and strange
experiences. Schizotypy spectrum. Artists etc.
David Bowie example.
Examples from the group – what do they want to
get out of the sessions. Fill in goal form.
Characteristics of unshared reality.
Idea of the line/ the threshold.
Importance of being able to manage the line
Motivational aspect – pros and cons.
Coping skills to manage the line
When is unshared reality most powerful; in charge?
Arousal as a means of being in control;
Stress management
Being alert and concentrated – watch out for drifting states
Grounding in the present
Wise mind and mindfulness
Focusing/mindfulness v. distraction
Session 2. The role of Arousal
shaded area = anomalous experience/symptoms are more accessible.
Level of
Arousal
High Arousal - stress
Ordinary, alert, concentrated, state of arousal.
Low arousal: hypnagogic; attention drifting etc.
Session 3: mindfulness & 4: making
sense.
Introducing Focussing. Haddock research on Focussing
and Distraction.
Mindfulness and focussing.
Mindfulness exercise.
******************************************************How do
people make sense of their experiences? Disussion of
different ways of making sense of them.
Clue: what was happening when they first started?
Feedback, summing up and completing the goal sheet
again.
The Challenge of Evaluation in
the Inpatient Setting
People in crisis are not keen to fill in a lot of questionnaires
– and are not very good at it.
We are prepared to open the programme to people who
are quite floridly psychotic – not so easy to obtain
measures from this group.
Even with only 4 sessions, consistency of attendance and
retention are a problem
CSIP grant enabled us to employ an Assistant one day a
week for 6 months in order to evaluate the group
Measures
CORE – routine measure and to gage level
of pathology
Mental Health Confidence Scale
Visual Analogue Goal Setting Scale –
administered as part of the first session.
Satisfaction Questionnaire at the end gave
us some idea of impact on individuals
Questionnaire Results
Because of high rates of attrition and difficulties
obtaining questionnaires in some cases, only 15
complete data sets were achieved
Significant self rating of achievement of goal for
group attendance
Mental Health Confidence Scale: overall results
not significant. Only the ‘Coping’ subscale
showed significant improvement;’Optimism’ and
‘Advocacy’ subscales did not reach significance
- the trend was in the right direction
Satisfaction Data
Question 1: What was most helpful about the
group? – Universality cited:
Nice to hear other people open up…
Being able to talk and understand each other
Q2: What was least helpful about the group?
Other people talking too much
Should be earlier and more intense
Q3: Has it made you think differently about
anything? If so, please tell us about this.
It made me think about things in my thoughts
I feel clearer about what’s real and what’s not,
what to share and what is personal
Yes without a doubt. I feel better about myself
Q4: Please tell us what, if anything, has changed
in the way you think about your mental health
issues since attending the group.
Yes, I am thinking of more positive things about my
life
I have now realised that I in-fact do have a
problem
Q5: Please tell us what, if anything, has changed
in the way you view yourself since you attended
the group.
Feel less isolated about the way I see things
I have become more confident
Q6: What kind of things did you learn in the group?
Using mindfulness
To be open, to think about what you are thinking,
to be self-aware
Open Comments: wanting the group to have been
longer.
Wider Influence
AOT became interested as the group drew in
previously unengageable clients – co-facilitated
A 12 session community version was developed –
with the help of a focus group of service user
graduates
Attended by AOT and CMHT clients
This is being more thoroughly evaluated and will
be written up
Service user report of impact in the chapter on the
approach in the Second Edition of Psychosis
and Spirituality.
Contact details, References and Web
addresses
Isabel.Clarke@hantspt-sw.nhs.uk
AMH Woodhaven, Calmore, Totton SO40 2TA.
Clarke, I. (Ed.) Forthcoming Psychosis and Spirituality: consolidating the new paradigm.
Chichester: Wiley
Clarke, I. ( 2008) Madness, Mystery and the Survival of God. Winchester:'O'Books.
Clarke, I. & Wilson, H.Eds. (2008) Cognitive Behaviour Therapy for Acute Inpatient
Mental Health Units; working with clients, staff and the milieu. London: Routledge.
Durrant, C., Clarke, I., Tolland, A. & Wilson, H. (2007) Designing a CBT Service for an
Acute In-patient Setting: A pilot evaluation study. Clinical Psychology and
Psychotherapy. 14, 117-125.
Phillips,R., Clarke, I. & Wilson, H.(in preparation) Evaluation of an Inpatient Group CBT
for Psychosis Program Designed to Increase Effective Coping and Address the
Stigma of Diagnosis Psychosis.
www.isabelclarke.org
www.SpiritualCrisisNetwork.org.uk